Audiology Advocacy

Audiologists responsibility to EHDI

Mary Beth Brinson, Au.D.

Stephanie Disney, M.S. CCC-A

Presentation Points

Historical Perspective Survey comparisons Audiological services comparison Pediatric Audiology Crisis Professional Organizations and Plans Au.D. solutions Case Studies Problem solving and discussion

Historical Perspective

In 2000, Kentucky audiologists were surveyed about pediatric audiology protocols, equipment availability, training needs and resources, and community collaboration

54% of those surveyed responded (41/75)

Access to services by age

5

7884

95

0102030405060708090

100

% testing

0 6 12 36

test age in months

Based on 2000 survey

Test Protocol

90

75

24

97 95

0102030405060708090

100

% testing

Tymp OAE ABR Puretone

HA

Test Protocol

Based on 2000 survey

Training NeedsBased on 2000 survey

50

28 30 28

05

101520253035404550

% interested

None OAE CI ABR

Training requested

EI Training

13

6352 50

010203040506070

% interested

Non

e

Com

mu

nit

yR

esou

rces

Lan

guag

eS

tim

Inte

grat

ion

Training requested

Based on 2000 survey

Distribution of Audiologists

Pediatric Audiology Crisis

Paradise and Bess (1994) article: Predicted inability to provide quality follow-up from UNHS due to high numbers

Speculated that there were not enough qualified professionals

High Risk Registry vs. UNHS

High risk registry: misses estimated 50% of permanent childhood hearing loss

Crisis is that theoretically we have doubled the babies entering the system

Where are the additional qualified providers?

JCIH 2000

EHDI GUIDELINES

8PRINCIPLES

Audiology Test Battery

Includes physiological measures Includes developmental

appropriate behavioral techniquesMeasures that assess integrity of

the auditory systemEstimate for each ear type, degree

and configuration of hearing loss

JCIH Guidelines(6 through 36 months)

Family and child history Behavioral Response Audiometry (CPA,

VRA)* Otoacoustic emissions Acoustic emittance measures Speech detection and recognition

measures* Electrophysiologic (ABR) testing: at least

once*

*requires special adaptations for pediatrics

JCIH Guidelines(0 through 6 months)

Family and child history* Frequency specific electrophysiological test

(ABR or ASSR)/Bone conduction* Otoacoustic emissions Middle ear function test/ ART* Behavioral Observation Audiometry*

*Requires special adaptations for pediatrics

“Adequate confirmation of an infant’s hearing status cannot be obtained from a single test measure. A battery cross-checks findings of both physiological and behavioral measures.”JCIH

Confirmation of Hearing Loss: Benchmarks

Comprehensive services coordinated between the medical home, family and related professionals with expertise in hearing loss.

Audiologic and medical evaluations before 3 months of age or 3 months after discharge for NICU infants

Infants with diagnosed hearing loss receive and otologic evaluation

The medical and audiologic evaluation process perceived as positive and supportive

Clinical Doctorate?

Percent of Audiologist who hold an Au.D. by State

June 2004

1-4%

5-9%

10-14%

15-19%

20-24%

19-25%

Training?

Total number of NCHAM training workshops completed: 14 Total number of audiologists trained: 299 Areas workshops located:

2002 Florida

2003 Iowa, San Diego, Redondo Beach, Oakland,

Chicago (CA had a separate grant)

2004 Salt Lake City, Boston, Redondo Beach, Boise

Philadelphia,Redondo Beach, San Mateo, New Orleans

2005 Next one scheduled is in New Mexico

Credentialing?

Still being developed…… Doesn’t address today’s needs

Case Studies

Case Study 1

Risk factors include:Sepsis

Ototoxic MedicationsPrematurity

Behavioral explanation, no cross

check? Multi system evaluation?

Notched tymp due to crying?

No Cross CheckParental report of cessation of babbling at 11 monthsRECHECK in 6 months?

A cross check now?

Is this matching results to middle

ear measures?

Post op tubes – Behavorial excuse for

hearing loss?

Questionable microphonic

Questionable microphonic

Audiological Findings

Severe to Profound Bilateral SNHL Functional PE tubes Recommend immediate amplification

-There are no OAE’s and a lack of systemic

evaluation and cross check battery

Ear specific?

Cross check?OAE’s?

Fit with powerful Phonak Sonoforte 2 P3AZ HA

Pre Cochlear Implant Evaluation

? OAE

Audiological Recommendations

Re-program hearing aid to new hearing loss

-Only obtained thresholds at 500, 2K Re-evaluate with behavorial testing in 3

months

-Parents report child has no speech

-No physiologic measures planned

Middle ear evaluated-Tympanometry

Cochlear function evaluated- OAENeural track evaluated- ABR

Frequency Specific information

90 dB85 dB

Audiological Recommendations

Diagnosis- Auditory Neuropathy Discontinue current amplification Consider mild gain aid Proceed with Cochlear Implant Evaluation

Identified with a hearing loss so late in the critical language learning period, she is at a disadvantage in the language learning process

Late age of identification and upcoming use of Cochlear Implant……………..

Stephanie:

Sorry I haven’t followed up with you sooner, but it has been crazy!!! I got your phone message and wanted to follow up with you. You were right about the Neuropathy. Sue Windmill made the diagnosis in April!!! We consulted with Dr. Linda Hood at LSU, and Vanderbilt agreed to do the implant surgery!!! She was implanted on April 28th and switch on was May 26th. She has been in AV therapy since that time, and seems to be coming along. We have a very long way to go, and are uncertain about the full outcome at this point? I have been on the LSU website, but would love to get more information on AN if I can? Any suggestions where I might find research or other resources?Thank you again for helping us get a diagnosis. If you had not helped us, we would still be searching for the answer.

I can’t thank you enough.

Sincerely,

Christy Adkins

A different take on 1-3-6

6 Audiologists 3 Centers in 2 states 1 Late Diagnosis

Case Studies

Case Study 2

Case 1: TM

Male Born August 2004 Failed UNHS bilaterally No reported risk factors Normal pregnancy and birth

Case 1:T.M.

UNHS follow-up 8/21/04 ABR Results…

ABR 1Results: T.M.

Right ear:60dB

ABR 1Results: T.M.

Artifact90

Sweep2000

Left ear:60dB

Tympanogram 1: T.M.

Tymps @

226Hz @

4 weeks

Inappropriate test settings

OAE 1: T.M.

Interpretation of 1st ABR

Actual hearing could not be determined due to child’s awake state

Middle ear dysfunction right ear, normal left Audiologist not confident in findings

Attributed hearing loss results to high artifact Scheduled retest at 2 months of age

ABR 2: T.M.

Left ear:35dB

ABR 2: T.M.

Right ear:50dB

ABR 2: Results

Borderline normal hearing left Possible mild hearing loss right Again, awake state interfered with tests Recommendation: Sedated ABR due to high

artifact and for second opinion**

ABR 3: T.M.

Different facility Under sedation December 2004 Child is 5 months old

ABR 3: T.M.

ABR 3: T.M.

Bilateral moderate sensory hearing loss Earmold impressions made Early intervention referral made

Problems: T.M.

3 ABRs performed, 4 months for diagnosis High Artifact? < 10% 3rd ABR with sedation: unnecessary? 2 1/2 hour trip to other facility Parents now travel for hearing aid appts.

Possible Remedies

Correct tests were performed according to JCIH

More education in modifications for neonates

More experienced mentor to lend support Additional pediatric testing training (locally

and nationally available)

Not everything that is faced can be Not everything that is faced can be changed, but nothing can be changed changed, but nothing can be changed until it is faceduntil it is faced - -James BaldwinJames Baldwin